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Neuropsychiatric Evaluations and Treatment
Dr. Kant and his associates are experienced in evaluating patients suffering from depression, anxiety, head injury, MS, Stroke...





Child and Adolescent Psychiatry
We provide services for depression, anxiety, ADHD and other emotional and behavioral issues affecting children...





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Acupuncture is used for treating many pain problems and chronic medical conditions… Brochure





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Dr. Kant performs review of medical records and conducts IMEs when requested…




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Research


  1. Presence of post-concussion syndrome symptoms in patients with chronic pain vs mild traumatic brain injury
  2. Assessment and treatment of apathy syndrome following head injury
  3. Clozapine impact on clinical outcomes and aggression in severely ill adolescents with childhood-onset schizophrenia 
  4. Safety and Efficacy of ECT in Patients with Head Injury: A Case Series  
  5. Treatment of aggression and irritability after head injury
  6. Prevalence of apathy following head injury
  7. Tc-HMPAO SPECT in persistent post-concussion syndrome after mild head injury: comparison with MRI/CT
  8. Antidepressant efficacy and cardiovascular safety of venlafaxine in young vs old patients with comorbid medical disorders
  9. Clinical utility of clozapine in 16 patients with neurological disease
  10. Hemiballismus following closed head injury
  11. Obsessive-compulsive disorder after closed head injury: review of literature and report of four cases
  12. ECT as a therapeutic option in severe brain injury
  13. Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine
  14. Outcome of laminectomy for civilian gunshot injuries of the terminal spinal cord and cauda equina: review of 88 cases
  15. Treatment of Apathy Syndrome After Acquired Brain Injury - A Case Series
  16. Impact of Clozapine on Clinical Outcomes and Aggression in Severely ill in-Patients with Childhood Onset Schizophrenia
  17. Head Injuries in Children  (Letter published in Post Gazette, Pittsburgh, PA)
  18. Post Concussion Syndrome - A Neuropsychiatric Perspective
  19. Prevalence of apathy following head injury
  20. Apathy secondary to neurologic disease
  21. Apathy syndrome after head injury and treatment outcomes



Presence of post-concussion syndrome symptoms in
patients with chronic pain vs. mild traumatic brain injury.
Smith-Seemiller L, Fow NR, Kant R, Franzen MD.
PRIMARY OBJECTIVE: Post-concussion syndrome (PCS) is a controversial diagnosis, in part because many symptoms may be present in other conditions, such as chronic pain (CP). However, direct comparisons between people with CP and mild traumatic brain injury (MTBI) are limited. The purpose of this study was to compare people with CP and MTBI on a measure of PCS symptoms.

DESIGN: Group comparison between patients with CP and MTBI on the Rivermead Post-Concussion Questionnaire (RPCQ). METHODS: Sixty-three patients with CP and 32 with MTBI were evaluated at the authors' institutions. Patients completed the RPCQ as part of their initial evaluation.

RESULTS: No group differences were found for total RPCQ scores. There were some differences in the proportion of patients endorsing specific symptoms. However, most people with CP endorsed symptoms consistent with PCS.

CONCLUSIONS: PCS symptoms are not unique to MTBI, and may be seen in conditions such as CP.

Brain Injury 2003 Mar;17(3):199-206.

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Assessment and treatment of apathy syndrome following head injury
Kant R, Smith-Seemiller L.
Head Injury Clinic and Acupuncture Centers, Pittsburgh, PA 15017, USA. rkant@headinjury.com

NeuroRehabilitation. 2002;17(4):325-31.

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Clozapine impact on clinical outcomes and aggression in severely ill adolescents with childhood-onset schizophrenia.
Chalasani L, Kant R, Chengappa KN.
Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Mayview State Hospital, Pittsburgh, Pennsylvania, USA.

OBJECTIVE: To evaluate the impact of clozapine on aggressive behaviour and clinical outcomes in children and adolescents with schizophrenia or schizoaffective disorder.

METHODS: We reviewed the charts of 6 children and adolescents who were admitted consecutively to a long-term care facility for clinical outcomes, including seclusion and restraints incidents prior to and during clozapine treatment. We also present a representative case history.

RESULTS: We noted clinically significant improvements in social interaction and decreases in the number of violent episodes and homicidal or suicidal thoughts. The global assessment of functioning (GAF) scores improved significantly. Weight gain was significant.

CONCLUSIONS: These cases illustrate the benefits of clozapine treatment in refractory childhood-onset schizophrenia. Outcomes are similar to those described in adults. Even though open data limit conclusions from this study, it is pertinent that there was a clinically significant improvement in aggressive behaviours. This may be particularly important for improved morale of patients, their families, and treating staff. It may also be helpful in discharge to a less restrictive environment.

Can J Psychiatry. 2001 Dec;46(10):965-8

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Safety and Efficacy of ECT in Patients with Head Injury: A Case Series
Ravi Kant, M.D., C. Edward Coffey, M.D. and Antonia M. Bogyi, M.D.
Electroconvulsive therapy (ECT) is a safe and effective treatment for certain psychiatric disorders. Eleven patients who had sustained a closed head injury were treated with ECT for their psychiatric symptoms. Eight patients responded to an index course of ECT: 2 were partial responders and became responders during continuation ECT (cECT); 1 patient was a nonresponder. Post-ECT Neurobehavioral Cognitive Status Examination and Mini-Mental State Examination scores showed no significant decline (P>0.70 and P>0.89, respectively) from baseline. Eight patients received cECT, without any lasting cognitive side effects. These findings indicate that ECT can be used effectively in patients with a history of closed head injury, without adverse effects on cognitive functioning.

J Neuropsychiatry Clin Neurosci 11:32-37, February 1999

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Treatment of aggression and irritability after head injury
Kant R, Smith-Seemiller L, Zeiler D.
Thirteen patients who experienced problems with irritability and aggression following closed head injury (CHI) participated in a non-blind, 8 week open trial and sertraline HCl. Significant reduction in irritability and aggressive outbursts was observed. No significant changes were observed in depressive symptomatology. Results suggest that serotonergic agents may be useful in treating aggression and irritability after head injury. Further placebo-controlled studies using serotonergic agents are indicated.

Brain Injury. 1998 Aug;12(8):661-6.

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Prevalence of apathy following head injury
Kant R, Duffy JD, Pivovarnik A.
Although several studies have examined the demographics of mood disorders and personality changes following closed head injury (CHI), there are no studies that address the prevalence of apathy after CHI. Utilizing standardized evaluation tools; this study examines the prevalence of apathy in 83 consecutive patients seen in a neuropsychiatric clinic. A total of 10.84% had apathy without depression while an equal number were depressed without apathy; another 60% of patients exhibited both apathy and depression. Younger patients were more likely to be apathetic than older patients who were more likely to be depressed and apathetic. Patients with severe injury were more likely to exhibit apathy alone. Family members rated the patients higher on apathy scale. These findings suggest that apathy is a frequent symptom after head injury and may occur either alone or in association with depression.

Brain Injury. 1998 Jan;12(1):87-92.

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Tc-HMPAO SPECT in persistent post-concussion syndrome after mild head injury: comparison with MRI/CT
Kant R, Smith-Seemiller L, Isaac G, Duffy J.
The purposes of this study were: (1) to determine the prevalence of abnormal 99mTc-HMPAO SPECT scans in patients suffering from persistent post-concussive syndrome (PPCS) after mild closed head injury (CHI); (2) to compare SPECT with structural neuroimaging (MRI and CT) in patients with mild CHI; and (3) to investigate correlations between SPECT and clinical data obtained from the patient sample (neuropsychological testing, demographics, psychiatric diagnoses). Forty-three patients were included. SPECT was read as abnormal in 53% of patients and showed a total of 37 lesions while MRI was read as abnormal in 9% and CT scan in only 4.6% of patients after mild CHI. SPECT appears to be more sensitive in detecting cerebral abnormalities after mild CHI, especially in patients with PPCS symptoms, than either CT or MRI. No statistically significant relationship was found between SPECT scan abnormalities and age, past psychiatric history, history of substance abuse, or history of multiple CHI. Education level did not differ between patients with normal and abnormal SPECT. Current neuropsychiatric symptoms did not seem to have any impact on the results of SPECT scan.

Brain Injury. 1997 Feb;11(2):115-24.

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Antidepressant efficacy and cardiovascular safety of venlafaxine in young vs old patients with comorbid medical disorders  
Zimmer B, Kant R, Zeiler D, Brilmyer M.
OBJECTIVE: To determine whether venlafaxine exerts a differential effect on blood pressure in young versus old depressed patients. METHOD: We compared thirty-four consecutive patients treated with 50-250 mg/day venlafaxine for major depressive disorder or another major mood disorder at our medical college's ambulatory neuropsychiatry program. We obtained baseline and follow-up blood pressure measurements. Each patient also received a baseline and final Clinical Global Impressions (CGI) score; global improvement was determined by consensus of two clinicians.

RESULTS: Sixteen nongeriatric patients (age, 13 to 56 years) were compared with eighteen elderly patients (age, 65 to 86 years). Most patients (88%) had serious medical comorbidities or histories. Despite a higher mean daily venlafaxine dosage for patients in the young group, no significant changes in systolic blood pressure were noted in either group. For the older group, we found a non-statistically significant 4.7 mm Hg mean increase in diastolic blood pressure. No patient became hypertensive. We also found a negative correlation between baseline diastolic blood pressure and change in diastolic blood pressure during treatment with venlafaxine. This inverse relationship was statistically significant in the older patients.

CONCLUSIONS: Venlafaxine was not associated with significant, sustained changes in blood pressure in any patient receiving dosages of 50-250 mg/day. Minimal changes in diastolic blood pressure were no more likely to occur in older venlafaxine-treated patients than in younger ones. Higher baseline diastolic blood pressure in older patients, but not in younger ones, seemed to protect against diastolic adrenergic blood pressure effects of venlafaxine.

Int. J Psychiatry Med. 1997;27(4):353-64.

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Clinical utility of clozapine in 16 patients with neurological disease
JD Duffy and R Kant
Patients who develop psychosis or agitated behavior secondary to neurological disorders present a therapeutic dilemma. The authors review clinical efficacy and side effect profiles of clozapine in a cohort of 16 patients with various neurobehavioral disorders. One-third showed a marked decrease in symptoms while on clozapine. However, one- quarter developed an acute confusional state; of these, all had diffuse slowing on their baseline EEG prior to starting the drug.

J Neuropsychiatry Clin Neurosci 1996; 8:92-96

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Hemiballismus following closed head injury
Kant R, Zeiler D.
Movement disorders are relatively rare after closed head injury (CHI), but when present they can go unrecognized if clinicians are not aware of their occurrence. We are presenting a case of hemiballismus which was not recognized over 3 years and was labelled as malingering or as psychosomatic. The symptoms have responded significantly to pharmacological interventions. The SPECT scan of the brain showed the lesions in the subthalamic areas while MRI, CT scans of brain and EEGs were reported normal. It is concluded that one should be aware of the existence of movement disorders after mild to moderate CHI, and that SPECT scan of the brain should be considered if a patient is symptomatic and other neuroimaging studies prove 'normal'.

Brain Injury. 1996 Feb;10(2):155-8.

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Obsessive-compulsive disorder after closed head injury: review of literature and report of four cases
Kant R, Smith-Seemiller L, Duffy JD.
An increasing number of recent reports has pointed to the underlying neuropathological substrate for obsessive-compulsive disorder (OCD). Neuropsychological testing may suggest underlying organicity even though the neuroimaging studies and the neurological examination may be normal. Earlier reports are not in agreement about the laterality of deficits. Abnormalities in frontal regions, limbic areas and basal ganglia are noted in functional neuroimaging and neuropsychological studies. In closed head injury the damage tends to be diffuse, and it is not easy to clearly localize deficits or to determine their laterality. In this paper we review the various theories and literature on OCD and organicity, and report on four individuals who developed OCD symptoms after closed head injury. We also discuss their neuroimaging and neuropsychological testing results.

Brain Injury. 1996 Jan;10(1):55-63.

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ECT as a therapeutic option in severe brain injury
Kant R, Bogyi AM, Carosella NW, Fishman E, Kane V, Coffey CE.
Electroconvulsive therapy (ECT) is a safe, highly effective, and rapidly acting treatment for certain major psychiatric illnesses, most notably severe mood disorders. Disturbances in mood and behavior as symptoms of delirium may complicate recovery from traumatic brain injury, but virtually no data exist on the role of ECT as a treatment modality in such clinical situations. We describe a patient with severe, unremitting, agitated behavior following a severe closed head injury from a motor vehicle accident. The initial Glasgow Coma Scale score was 3, with computed tomographic evidence of bilateral frontal and left thalamic contusions. After awakening from a 21-day coma, the patient failed to improve beyond a Ranchos Los Amigos level 4 recovery stage. He exhibited persistent severe agitation with vocal outbursts and failed to assist in performing activities of daily living. His difficulties proved unresponsive to combined behavioral therapy and multiple trials of various psychopharmacologic agents. As an intervention of "last resort," he then received six brief-pulse, bilateral ECT treatments that resulted in marked lessening of his agitation and improvement in his ability to express his needs and participate in his self-care. Also, following the ECT, he showed a markedly enhanced response to psychopharmacologic agents. These findings may have important clinical implications for treatment of prolonged delirium after traumatic brain injury.

Convuls Ther. 1995 Mar;11(1):45-50

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Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine
Stone JL, Cybulski GR, Rodriguez J, Gryfinski ME, Kant R.
A retrospective review of the surgical experience in treating 18 patients with osteomyelitis of the cervical spine is reported. The patients ranged in age from 20 to 60 years and all complained of neck pain upon admission. Ten patients had a prior history of intravenous drug abuse, three had previously suffered penetrating injuries of the neck, and one had an extraspinal site of osteomyelitis. Bacteria were isolated in 13 cases and tuberculosis in three. Neurological abnormalities were present in over one-half of the patients, consisting of myelopathy (nine cases) or radiculopathy (four cases). Plain cervical spine films and polytomography demonstrated vertebral and end-plate destruction, spinal instability, and increased paravertebral soft-tissue shadow in all cases. Computerized tomography and, more recently, magnetic resonance imaging have proven helpful in detecting bone involvement and the presence of epidural extension associated with cervical osteomyelitis. The risk of vertebral body collapse, kyphosis, and myelopathy in the osteomyelitic cervical spine has standardized the management of this problem in this institution to consist of skeletal traction, needle aspiration or blood culture for organism identification, anterior cervical debridement, autogenous iliac graft fusion, and intravenous administration of antibiotics. Spinal stability and neurological improvement were achieved in all 18 patients.

J Neurosurgery. 1989 Jun;70(6):879-83.

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Outcome of laminectomy for civilian gunshot injuries of the terminal spinal cord and cauda equina: review of 88 cases
Cybulski GR, Stone JL, Kant R
Case records of 88 patients with low-velocity gunshot injuries of the terminal spinal cord and cauda equina treated by laminectomy at Cook County Hospital between 1969 and 1987 were reviewed. Sixty-one patients were operated upon within 72 hours of injury, 29 of whom (47.5%) experienced neurological improvement or pain relief. Twenty-seven patients were operated upon at a later time for associated injuries, 13 of whom (48.1%) experienced neurological improvement or pain relief. When laminectomy was delayed for more than 2 weeks, either arachnoid adhesions (15%) or occult abscesses (17%) were observed. From this review as well as from the literature, it appears that the timing of laminectomy for gunshot injuries of the thoracolumbar and lumbosacral spine is not essential to neurological recovery. It appears, however, that adequate debridement of these injuries, performed as soon as the patient is stable from any associated injuries, may help to mitigate the late sequelae of arachnoiditis, infection, and pain syndromes in the lower extremities.

Neurosurgery. 1989 Mar;24(3):392-7.

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Treatment of Apathy Syndrome After Acquired Brain Injury - A Case Series
Ravi Kant, MD
Abstract:
Apathy syndrome is a significant clinical problem in patients with neuropsychiatric sequalae after acquired brain injury (ABI). It may coexist with depression and impact the clinical picture and treatment outcomes. Results of treatment of apathy syndrome in this small sample of patients (N=19) with ABI are presented. Dopaminergic agonists were used for treatment and the response was measured with Apathy Evaluation Scale (AES) and Beck Depression Inventory (BDI). All of the 19 patients responded to treatment and improvement in apathy scores was statistically significant (p.004) and no significant change was noted in depression (p.22). (submitted for publication]

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Impact of Clozapine on Clinical Outcomes and Aggression in Severely ill in-Patients with Childhood Onset Schizophrenia
L. Chalasani, MD, R. Kant, MD, and K.N. Roy Chengappa, MD
Objectives: To evaluate the impact of clozapine on aggressive behavior and clinical outcomes in children and adolescents with schizophrenia or schizoaffective disorder.

Methods: Charts of six children and adolscents who were consecutively admitted to a long-term care facility were reviewed for clinical outcomes including seclusion and restraints incidents prior to and during clozapine treatment, and a representative case-history is presented.

Results: Clinically significant improvements were noted in social interactions, decreases were noted in the number of violent episodes, homicidal and suicidal thoughts. The global assessment of functioning scores improved significantly. There was significant weight gain.

Conclusions: These cases illustrate the benefits of clozapine in refractory childhood onset schizophrenia, similar to outcomes described in adults. Even though open data llimts conclusions from this study, it is pertinent that there was a clinically significant improvement with aggressive behaviors. This may be particularly important from the point of view of improved morale for patients, their families, and treating staff.

(submitted for publication]

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Head Injuries in Children
(Letter published in Post Gazette, Pittsburgh, PA)
This letter is regarding the May 25th article on traumatic injuries in children. One case of a severe head injury due to a skating accident was described. Most of the information was focussed on physical injuries. We would like to address the serious issues that arise after a head injury, especially in children.

Traumatic brain injury primarily affects cognitive abilities, such as short-term memory, attention, concentration, and learning new materials. Children have difficulty returning to their previous level of functioning at school. They may become hyperactive, irritable, aggressive and show other changes in their personality. They may show signs of ADHD with lack of concentration, easy distractibility, and difficulty to grasp new concepts. Their grades could start to decline. They may show significant mood swings ranging from rage outbursts to depression. These changes in a young child’s life lead to frustrations for parents, teachers, and the child himself. The children start to withdraw and develop problems with self-esteem and self-confidence. They may even become apathetic.

Other symptoms of head injury may include physical, emotional, behavioral, and neurological changes. These may include – headache, sleep problems, chronic pain, seizures, anxiety, depression, nightmares, disruptive behaviors, etc. Anxiety syndromes manifest as fearfulness, worry, and persistent tension. Depression is not easy to recognize in children and it can be very disabling. Unlike most injuries, such as a broken leg or a third-degree burn, the evidence of the trauma is often intangible, and the symptoms can be puzzling and unclear. Such an experience oftentimes is very stressful for the patient, his family, and his doctor.

Children are especially at high risk for head injury because of involvement in sports, bike riding, skating, swimming, vacation travel etc., more so in summer months. The use of a helmet, which for the state of Pennsylvania is a law for all children under the age of 12, is essential when riding a bike. Making sure the children are wearing a seatbelt and preferably ride in the back seat of an automobile. The effects of a head injury can be life long.

Most children show good recovery from a mild head injury over one to three months while the symptoms of severe head injuries usually persist. Anyone with symptoms beyond three months should seek further evaluation and treatments from specialists such as neurologists, child psychiatrists, or neuro- psychiatrists. Educating the family, teachers, and the patient is very important. Depression, anxiety, irritability, and problems with self-esteem and self-confidence can be treated with education, counseling, and medications. There are many organizations that provide support and information for patients and their families about brain injury. (Brain Injury Association at 703-236-6000; www.biausa.org )

Sincerely,
Ravi Kant, MD
Michele Bellini
Head Injury Clinic
Pittsburgh, PA 15017

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Post Concussion Syndrome - A Neuropsychiatric Perspective
Ravi Kant, M.D.
Introduction
More than two million closed head injuries (CHI) occur in this country in a year.Earlier studies had estimated the incidence rate of about 220/100,000 persons (1). Recent study by Sosin et al. (1996) estimates the incidence of mild to moderate head injury to be about 610/100,000 persons per year in a non-institutionalized population (2).This is almost three times what the earlier studieshave indicated. The earlier studies were based on retrospective reviews of hospital records. The highest rate ofCHI is for males at all ages (except 75 years and older) and peak rates are noted for males aged 15 - 24,rate for males being twice as high as that for females. The ratio of males to females decreases to nearly 1:1 after age 75 because mostof head injuries occur due to falls. The most common causes of CHI are motor vehicle accidents (MVA) (42%) and falls (20%).In almost 50% of head injury cases, intoxication is a contributing factor (1). About 85% ofCHIs are classified as mild. The rate of injury is inversely correlated with family income, the highest rates being in the lowest income group and were more often caused by MVA or assaults (3).

Mechanism of injury and pathophysiology
CHI causes trauma to the muscles, bones, ligaments, blood vessels, nerves in the neck and head in addition to an injury to the brain. All CHIs do not necessarily involve trauma to the brain. There are multiple physical forces involved, in addition to the neuro-chemical changes in the brain, which determine the severity of injury. The physical forces impacting on the brain include direct trauma to brain, coup-counter coup injury, rotational forces, pressure gradients, stretching of brain stem and spinal cord, changes in intra-cranial pressure, cerebral edema, contusions, and hemorrhages.CHI causes shear strain and diffuse axonal injury to the brain and hence, producing "multi-system" neurobehavioral symptoms. Frontal lobes are the most common site of injury (4) and temporal lobes are the next common site. Cerebral contusions and hematomas can be seen even after mild head injury. Severity of head injury is usually determined by Glasgow Coma Scalescore (GCS) (5) (Mild - GCS score of 13 - 15; Moderate - GCS score of 9 - 12, and Severe - GCS score of8).

Clinical Features
Common post concussion syndrome symptoms are physical, emotional, and cognitive(see table 1). Headache, sleep disturbance, dizziness, irritability, anxiety, cognitive slowing, difficulty in handling information, and short term memory problems (manifesting as forgetfulness, misplacing things, difficulty in learning new materials etc.) are commonly seen. Most of these symptoms abate in a few weeks to three months. In about 50% of patients, a few symptoms may persist beyond six months and about 10 -20% patients may go on having Persistent Post-Concussion Syndrome ( PPCS) i.e. two or more symptoms persisting beyond one year (6). These patients need comprehensive neuro-psychiatric evaluation and treatment focussed on head injury and its associated symptoms for proper rehabilitation and return to work.

Following are some of the common neuropsychiatricconditions seen after closed head injury.

Headache
Headache is the most common complaint after CHI. It is reported to have a greater frequency and duration after mild CHI compared to moderate or severe head injury. Cause for post- traumatic headaches is multi-factorial. These factors include soft tissue injury, neuroma formations, tissue scarring, entrapment of nerves in bony or fibro-muscular tissues, direct injury to nerves such as greater occipital nerves, vascular, and myofacial injuries. Post-traumatic headachesare of multiple types, and patients usually have more than one type. Essentially all types of headaches could be seen after CHI.Following types of headaches are commonly seen after CHI-migraine, tension-type, occipital neuralgia, cervicogenic, basilar artery migraine, and dysesthesia due to posterior cervical sympathetic nerve injury. Detailed history should be taken to evaluate the headaches and look for psychological and social factors, including legal issues. Treatments should be based on the type of headache and also eliminating or minimizing the exacerbating factors.Psychological and legal issues should be addressed as needed. Avoid use of narcotics and other medications with addicting potentials.

Depression
Depression is reported in 25 to 50% of patients after head injury (7).It is one of the most disabling conditions after head injury that the patients experience. Depression negatively affectsthe family and social relationships. It also have impact on cognitive functioning and ultimately delays return to premorbid level of funtioning. Depressed patients cannot effectively participate in rehabilitation services. There is some controversy about the underlying cause- whether it is psychogenic, biological, or both. The frontal lobes are the most common site of injury to the brain after a CHI (4) and frontal lobe dysfunction is commonly seen in patients with endogenous depression. Other factors contributing to depression may be physical, social, and cognitive changes following injury which include headaches, insomnia, inability to work, dependency, social withdrawal, discouragement, and demoralization along with cognitive difficulties described above. Because of all of these changes going on concurrently, it is difficult to separate biological from psychogenic factors. There may be a difference in the degree of contribution of these factors in each patient and at different stages of recovery.

Anti-depressants and other treatment modalities can be used for treatment of depression including electroconvulsive therapy (ECT). ECT has been effective in treating depression after head injury. We have successfully treated 13 such patients with ECT (8,9). In some cases, depression becomes chronic, refractory, and is difficult to treat. Careful attention should be paid in selecting an anti-depressant because of their cognitive side effects. Anti-cholinergic side effects of the tricyclic anti-depressants (cause dry mouth, constipation etc.)can impair memory, concentration, and attention span.

Anxiety
Anxiety is another common condition seen after head injury.There are no prospective studies to estimate the incidence of anxiety syndromes, but it has been reported to occur in 10 to 50% of patients.Generalized anxiety manifests as fearfulness, worry, persistent tension, and intense feeling of anxiety.Obsessive-compulsive behaviors have been seen, at times manifesting as a full-blown syndrome of an obsessive-compulsive disorder (10). At times, a person may have a catastrophic reaction to an acute situation. Post traumatic stress disorder (PTSD) is also seen in some patients, especially those who did not lose consciousness.PTSD in itself can lead to symptoms of depression, cognitive deficits, behavior changes such as anger and irritability, and somatic symptoms of sleep and appetite disturbance. Treatment usually involves educating the patient and the family, providing a supportive environment, and at times medication.Anti-anxiety medications should be selected very carefullybecause of their potential of dependance and worsening of cognitive deficits.

Personality Change
Personality changes are one of the most significant problems seen after head injury. Family members frequently complain that the patient is a totally changed person after the injury. Sometimes this is an exacerbation of a person’s pre-morbid personality traits. Some patients become aggressive and disinhibited on one extreme while others may become apathetic and lack initiative on the other extreme. Apathetic patients look depressed and hence mistakenly treated with antidepressants. We conducted a study to estimate the incidence of apathy after CHI. We found that apathy occurs in about 11% of patients seeking treatment for neuro-psychiatric problems after head injury (11). At times patients become very labile and paranoid, and some patients develop childish behavior. These extreme changes are seen after moderate to sever CHI. Personality changes can also be secondary to temporal or frontal lobe seizures. Some of these symptoms can be treated by behavior modification and medications, while for others, patient and family education and environmental changes are needed.

Cognitive Deficits
Cognitive changes involve problems with short-term memory, attention, concentration, information processing, difficulty making decisions, and executive functioning. Long term memory usually remains intact after mild to moderate CHI. Patients are forgetful about simple things such as telephone numbers, names, faces, and daily tasks. They get confused in over stimulating environments such as malls, large grocery stores, and large crowds. Patients have difficulty learning new materials. This in itself causes a lot of frustration, anger, and other emotional difficulties. At times, it is difficult to carry out simple tasks because of executive dysfunction. This leads to despondency, self-doubt, and frustration.Treatment of underlying conditions such as depression, anxiety, insomnia, chronic pain etc. improves the cognitive status. Some patients may need cognitive retraining and/or medication interventions for improving their cognitive status.

Psychosis
Perceptual changes are commonly seen in the early phase of brain injury, especially in the subacute phase.However, psychotic symptoms can also happen a few months to many years after the injury. It can manifest as hallucinations, delusions, paranoia, or any other perceptual disturbances.Sometimes psychotic symptoms are secondary to temporal lobe seizures. Overall, incidence of perceptual disturbances is very low, except for in the acute and sub-acute phase.

Other
Some unusual or late sequelae ofclosed head injury include anosmia, chronic pain syn­drome, seizures, endocrine disorders due to injury to hypothalamic - pituitary axis,dystonia,hydrocephalus, cortical atrophy, aneurysms, sleep-wake cycle alteration(12), movement disorders including hemiballismus (13),and somatization disorders. Clinicians should be aware of these conditions and should not label the patient as malingering or having conversion reaction without proper evaluation.

Treatment
Wait and see approach should be employed in the first few weeks after injury except for conservative symptomatic treatments for pain and insomnia. Patients with continued disabling symptoms of cognitive, behavioral, or emotional changes four weeks or so after injury or if symptoms are getting worse, should be referred for comprehensive neuro-psychiatric evaluation. It is very important to establish the baseline severity of symptoms early and follow the progression of symptoms. It is especially important in patients with mild head injury because their primary disability usually arises from neuro-psychiatric symptoms.

Evaluation should be done by someone who is familiar with and have experience in evaluating and treating patients with head injuries. Comprehensive evaluations may include neuro-psychiatric evaluation, neuro-psychological testing, neuro-imaging such as MRI and/or SPECT scan of brain, EEG, and neuro-rehabilitation evaluation. Also, assess for individual and/or familytherapy, cognitive retraining, chronic pain program, and vocational retraining.

Treatment process involves educating the patient and his/her family members, on-going evaluations, and comprehensive treatment strategies which may involve identifying and treatingphysical, emotional, cognitive, and neurological symptoms. Appropriate referrals to neuro-psychology, rehabilitation, and neurology should be considered. Careful selection of medications is very important as some of the commonly used medications can have significant negative effects on the motor and/or cognitive recovery process. Outcome measures should be utilized to measure the baseline severity of symptoms, progression, and response to treatments.

Prognosis
Following factors favor good outcome - young age, no past CHIs, no history of substance abuse, good family support, married, no past history of disabilities, stable and high skill job, and above average intellectual functioning.

References
1.Krause JF, Sorenson SB. Epidemiology. In: Silver JM, Yudofsky SC, Hales RE, eds. Neuropsychiatry of Traumatic Brain Injury. Washington, DC: American Psychiatric Press Inc. 1994:3‑41.
2.Sosin DM, Sniezek J, Thurman DJ. Incidence of mild to moderate brain injury in the United States, 1991. Brain Injury. 1996;10:47‑54.
3.Cooper JD, Tabaddor K, Hauser WA. The epidemiology of head injury in the Bronx. Neuroepidemiology. 1983;70‑88.
4.Mattson AJ, Levin HS. Frontal Lobe dysfunction following closed head injury. Journal of Nervous and Mental Disease. 1990;178:282‑91.
5.Teasdale G, Jennett B. Assessment of coma and impairment of consciousness: a practical scale. Lancet. 1974;81‑4.
6.Alexander MP. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology. 1995;45:1253‑60.
7.Jorge RE, Robinson RG, Starkstein SE, et. al. Comparison between acute and delayed onset depression following traumatic brain injury. J Neuropsychiatry Clin Neurosci. 1993;5:43‑9.
8.Kant R, Bogyi A, Carosella N, Fishman E, Coffey CE. ECT as a therapeutic option in severe head injury. Convulsive Therapy. 1995;11:45‑50.
9.Kant R, Bogyi A, Coffey CE. ECT after traumatic brain injury. Convulsive Therapy. 1995;11:[Abstract]
10.Kant R, Seemiller L, Duffy J.D. Obsessive compulsive disorder after closed head injury: Review of literature and report of four cases. Brain Injury. 1996;10:55‑63.
11.Kant R, Duffy J, Pivovarnik A. Prevalence of apathy following closed head injury. Unpublished data. 1996.
12.Bachman D. L. The diagnosis and management of common neurologic sequelae of closed head injury. J Head Trauma Rehabil.. 1992;7(2):50-59.
13.Kant R, Zeiler D. Hemiballismus following closed head injury ‑ case report. Brain Injury. 1996;10:155‑8.

Table 1Common Post-Concussion Syndrome Symptoms

Physical
1. Headache
2. Dizziness
3. Sleep disturbance
4. Diplopia and blurring of vision
5. Light and sound sensitivity
6. Neck pain
7. Tinnitus (ringing in ears)
8. Fatigue

Emotional
9.Anxiety
10. Irritability
11. Depression
12. Mood lability

Cognitive
13. Slowed thinking
14. Short-term memory problems
15. Impaired concentration and attention span
16. Periods of confusion
17. Difficulty learning new materi

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Prevalence of apathy following head injury
R. Kant, J. D. Duffy, and A. Pivovarnik
Although several studies have examined the demographics of mood disorders and personality changes following closed head injury (CHI), there are no studies that address the prevalence of apathy after CHI. Utilizing standardized evaluation tools, this study examines the prevalence of apathy in 83 consecutive patients seen in a neuropsychiatric clinic. A total of 10.84% had apathy without depression while an equal number were depressed without apathy: another 60% of patients exhibited both apathy and depression. Younger patients were more likely to be depressed and apathetic. Patients with severe injury were more likely to exhibit apathy alone. Family members rated the patients higher on apathy scale. These findings suggest that apathy is a frequent symptom after head injury and may occur either alone or in association with depression.

Brain Injury, 1998, vol. 12, No. 1, 87-92.

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Apathy secondary to neurologic disease
James D Duffy and Ravi Kant
The phenomenology and treatment response of secondary psychiatric disorders provides a valuable model for exploring the pathophysiology of primary psychiatric disorders. This article provides a broad overview of (1) case reports that have applied a "lesion analysis" approach in studying apathy and related disorders of diminished motivation (ADDM) and (2) studies that have used standardized assessments of apathy in well-defined populations of patients with neurologic disorders. This rapidly expanding clinical database provides a valuable resource for defining the neural substrates of motivation and its clinical disorders.

Psychiatric Annals 27:1/January 1997

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Apathy syndrome after head injury and treatment outcomes
Ravi Kant, M.D.
Emotional and personality changes are common after head injury. Aggression and irritability are frequently reported but apathy is also noted to cause significant disability. Apathy is at times mistaken for depression. We conducted a study to estimate the prevalence of apathy after head injury in a clinical population and response to treatments. Apathy Evaluation Scale-Self (AES-S) and Beck Depression Inventory (BDI) were used at initial evaluation and follow up visits in 83 patients with CHI- 73.5% male; mean age 38+12.27; 74.7% mild CHI. Family members completed the informant version - AES-I. Ten patients were treated for apathy syndrome with methylphenidate. Of the 83 patients, 9 (10.84%) were apathetic without depression and same number were depressed without apathy. 50 (60.24%) were both depressed and apathetic while 15 (18.07%) had neither. Family members rated patients significantly higher on AES (p.000001). Younger age (p.04) and higher severity of injury (.01) correlated with apathy.

AES scores improved after treatment for twelve weeks with methylphenidate in ten patients (p.004). Similar change in AES - I scores was noted (p.01). BDI scores did not change (p.227). These gains were maintained on long term treatment (Ave. 11 months). We believe apathy is a frequent symptom after CHI and it responds well to dopaminergic agents. It appears to be an independent entity, but may co-exist with depression.

(Submitted for publication)

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